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If You Can’t Frown, Might You Be Less Depressed?

Putting on a happy face might just lead to feeling better.

Leonardo da/Shutterstock
Source: Leonardo da/Shutterstock

The “lipstick test” has been an indicator, albeit a non-scientific one, of the beginning of recovery from a serious illness or operation. When a patient feels well enough to pay attention to his or her appearance by shaving or putting on a minimal amount of make-up (lipstick), the physician knows that the pain is receding, strength is returning, and optimism about recovery is appearing. Now it seems that treatments which remove facial signs of depression, anger or despair might also affect how a patient feels. The treatment is injections of botulinium toxin, better known as Botox, into the forehead of patients suffering from a variety of mental disorders.

Botox is a drug made from an extremely dangerous neurotoxin produced by the bacterium Clostridium botulinum. If ingested in spoiled food, it can cause a life-threatening type of food poisoning called botulism. However, when injected in tiny amounts, Botox causes muscle paralysis, thus smoothing out the wrinkles and frown lines in the skin above the muscles. The effect is not permanent, but until it wears off, people whose frown lines made them appear as if they were in a perpetually bad or petulant mood will appear better humored.

Several studies have tested the effect of removing (or obscuring) these lines on decreasing depression and other mood disorders. Botulinum toxin, or Botox, is injected in the area between the eyebrows and above the nose. This site, the glabella, is where vertical frown lines usually appear (even if one doesn’t frown). In one such study, about 40 people with chronic depression who did not respond to conventional treatments were injected with Botox in the glabellar area. The treatment did not remove their depression entirely, but reduced the scores evaluating the severity of their depression by 27%. In a related study, Wollner et. al. found that injections of Botox diminished the depression of patients with bipolar disorder; their depression returned once the effects of the Botox wore off.

Although it might appear that erasing frown lines is sufficient to relieve clinical depression, the reason for the relief may be more complicated. Indeed, Finzi and Rosenthal, suggest there is no relationship between looking better and feeling less depressed. In some cases, patients who did not have visible frown lines when their facial muscles were at rest still became less depressed after Botox treatment. Other patients who didn’t like their change in expression after treatment with Botox also showed a positive change in mood. According to Finzi and Rosenthal, the improvement in mood was due to changes in the brain produced by nerve impulses traveling to the brain’s emotional center, the amygdala, after Botox treatment. For example, normally when someone is exposed to angry expressions of other people, the amygdala shows increased activity. But paralyzing frown muscles by Botox injections actually reduced the activity of the amygdala after patients saw pictures of angry people. Clearly, the improvement in mood detected in many studies is not due to pleasure at the removal of furrows between the eyes, but associated with changes in brain activity.

More research is needed to understand better how Botox treatment works to help those suffering from depression, a complex disease with both emotional and physical symptoms. Even if Botox treatment, which affects the muscles in the forehead ultimately alters the information transmitted by various nerves to the emotional center of the brain, it is unclear how this can relieve the symptoms of depression. Moreover, there is not much information as to whether the effects of Botox can be amplified by treatment with antidepressants, and/or talk therapy, or whether it should be tried before starting a patient on antidepressants.

Typically the effect lasts no longer than three months; after that the depression returns. Thus for their effect on depression to persist, Botox injections need to be repeated frequently. The injections are expensive, and there may be side effects such as pain near the injection site, droopy eyelids, or eyebrow and headache. Where would the patient get the Botox? Dermatologists and plastic surgeons are two medical specialists who usually administer Botox. With this breakthrough therapy however, are we going to see the emergence of Dermopsychiatrists? The long-term consequences of frequent Botox injections have not been studied; does their efficacy wear off with repeated injections? Nor have any large scale studies been carried out comparing the efficacy of Botox against treatment with antidepressant drugs.

Research into the neurological changes produced by Botox injections and subsequent improvement in depression may open the way to a better understanding of the etiology of depression itself. Botox may become a research tool along with being a treatment.


“Botulinum Toxin,” Nigam P and Nigam A, Indian J Dermatol. 2010; 55: 8–14.

“Botulinum toxin as a treatment for depression in a real-world setting,” Chugh S, Chhabria A, Jung S, Kruger T, Wollmer M, Journal of Psychiatric Practice 2018;24:15-20.

“Botulinum toxin therapy of bipolar depression: A case series,” Finzi E1, Kels L2, Axelowitz J3, Shaver B3, Eberlein C4, Krueger T4, Wollmer M, J Psychiatr Res. 2018 ;104:55-57.

“Botulinum Toxin for Depression? Emotional Proprioception,” Finzi E and Rosenthal N, Psychiatric Times 2017 ;34: 1-3.

“Emotional proprioception: Treatment of depression with afferent facial feedback,” Eric Finzi and, Norman E. Rosenthal, J of Psychiatric Research 2016; 80: 93-96.

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